Allocation of very scarce medical interventions such as organs and vaccines is a persistent ethical challenge. We evaluate eight simple allocation principles that can be classified into four categories: treating people equally, favouring the worst-off, maximising total benefits, and promoting and rewarding social usefulness. No single principle is sufficient to incorporate all morally relevant considerations and therefore individual principles must be combined into multiprinciple allocation systems. We evaluate three systems: the United Network for Organ Sharing points systems, quality-adjusted life-years, and (...) disability-adjusted life-years. We recommend an alternative system—the complete lives system—which prioritises younger people who have not yet lived a complete life, and also incorporates prognosis, save the most lives, lottery, and instrumental value principles. (shrink)

This article addresses the question of whether the relation of moral preference is transitive. I argue, following Larry Temkin and Stuart Rachels, that any ethical theory complex enough to be even minimally plausible allows us to generate intransitive sets of preferences. Even act utilitarianism cannot avoid this predicament unless we accept its least plausible version. We must reevaluate the assumption that an ethical theory must be transitive in order to be rational. This problem amounts to a foundational crisis in ethics. (...) However, it has not been taken seriously for two reasons—the belief that the problem has limited scope; and the claim that arguments against transitivity are 'merely' Sorites arguments. This article responds to both of these objections. I also point out some connections between intransitivity and the debate surrounding skepticism about the moral significance of numbers. (shrink)

The allocation of scarce health care resources such as flu treatment or organs for transplant presents stark problems of distributive justice. Persad, Wertheimer, and Emanuel have recently proposed a novel system for such allocation. Their “complete lives system” incorporates several principles, including ones that prescribe saving the most lives, preserving the most life-years, and giving priority to persons between 15 and 40 years old. This paper argues that the system lacks adequate moral foundations. Persad and colleagues' defense of giving priority (...) to those between 15 and 40 leaves them open to the charge that they discriminate unfairly against children. Second, the paper contends that the complete lives system fails to provide meaningful practical guidance in central cases, since it contains no method for balancing its principles when they conflict. Finally, the paper proposes a new method for balancing principles of saving the most lives and maximizing life-years. (shrink)

In "Futurc Generations: Further Problems,"‘ and Part Four of Reasons and Persons} Derek Pariit raises many perplexing questions. Although some think his ingenious arguments little more than delightful puzzles, I believe they challenge some of our deepest beliefs. In this article, I examine some of Pariit’s arguments, focusing mainly on "The Mere Addition Paradox." If my analysis is correct, Parfit’s arguments have extremely interesting and important implications that not even Pariit rcalized. In Part I, I present ParHt’s argument for the (...) Merc Addition Paradox, and show that given Pa.rHt’s assumptions, a radical conclusion seems t0 follow; the notion of "bctter th2m"—indced, even the notion of "aH things.. (shrink)

Ethicists and economists commonly assume that if A is all things considered better than B, and B is all things considered better than C, then A is all things considered better than C. Call this principle Transitivity. Although it has great conceptual, intuitive, and empirical appeal, I argue against it. Larry S. Temkin explains how three types of ethical principle, which cannot be dismissed a priori, threaten Transitivity: (a) principles implying that in some cases different factors are relevant to comparing (...) A to C than to comparing A to B or B to C; (b) principles of limited scope; (c) principles implying that morally relevant differences in degree can amount to differences in kind. My counterexamples employ a principle of type (c): pleasures and pains enormously different in intensity differ in kind. Temkin has also endorsed this type of counterexample, using arguments based on earlier drafts of this paper. (shrink)